Benign prostatic hyperplasia: a global challenge of the ageing population
Authors: Nicolas Sayegh, Kelli Gross
Journal: The Lancet Healthy Longevity (2022)

Demographic changes related to a consistent improvement in life expectancy are undeniably increasing the proportion of ageing populations across the world. Consequently, with this demographic transition comes the challenge of diagnosing and treating comorbidities associated with older age. In The Lancet Healthy Longevity, the GBD 2019 Benign Prostatic Hyperplasia Collaborators investigate the global burden of benign prostatic hyperplasia and its implications in terms of disability-adjusted life-years (DALYs).1GBD 2019 Benign Prostatic Hyperplasia CollaboratorsThe global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Healthy Longev. 2022; (published online Oct 20.)https://doi.org/10.1016/S2666-7568(22)00213-6Google Scholar Using international clinical administrative data from three locations and hospital inpatient admissions data from 45 locations, they show a rise in absolute cases of benign prostatic hyperplasia and the DALY burden due to benign prostatic hyperplasia between 2000 and 2019, with steady age-standardised prevalence and age-standardised DALY rates during this period. Low-income and middle-income countries accounted for the biggest variation in the prevalence of, and DALY burden attributed to, benign prostatic hyperplasia. These trends might be related to an improvement in diagnosis of benign prostatic hyperplasia, an adaptation phase of health-care systems to a growing patient population, as well as an increase in risk factors in these countries (notably, the rising prevalence of obesity and metabolic syndrome). By contrast, high-income regions showed a decrease in age-specific DALY rates associated with benign prostatic hyperplasia, most probably translating into a constant improvement in treatment and control of modifiable risk factors. The burden of benign prostatic hyperplasia on health-care systems is irrefutable and should be addressed as a whole. In the UK, the annual cost of medical management for benign prostatic hyperplasia (α-blockers and 5α-reductase inhibitors) was estimated at around £69 million in 2007–08, while the cost of hospital-treated benign prostatic hyperplasia (including surgery and the management of complications) was estimated at around £101 million.2Kirby RS Kirby M Fitzpatrick JM Benign prostatic hyperplasia: counting the cost of its management.BJU Int. 2010; 105: 901-902Crossref PubMed Scopus (36) Google Scholar Similarly, in the USA, the annual direct cost of benign prostatic hyperplasia treatment, excluding outpatient medications, was as high as $1·1 billion in 2000.3Wei JT Calhoun E Jacobsen S Urologic diseases in America project: benign prostatic hyperplasia.J Urol. 2008; 179: S75-S80Crossref PubMed Scopus (177) Google Scholar In a large-scale retrospective study analysing insurance and Medicare claims between 2004 and 2013, Welliver and colleagues4Welliver C Feinstein L Ward JB et al.Trends in lower urinary tract symptoms associated with benign prostatic hyperplasia, 2004 to 2013: the Urologic Diseases in America Project.J Urol. 2020; 203: 171-178Crossref PubMed Scopus (22) Google Scholar showed that the use of outpatient medical treatment for 4Welliver C Feinstein L Ward JB et al.Trends in lower urinary tract symptoms associated with benign prostatic hyperplasia, 2004 to 2013: the Urologic Diseases in America Project.J Urol. 2020; 203: 171-178Crossref PubMed Scopus (22) Google Scholar benign prostatic hyperplasia has been increasing over time. Interestingly, younger men (aged <64 years) preferred medical treatment with the preservation of sexual function, while the frequency of surgical intervention increased with age. Numerous studies have already shown that lower urinary tract symptoms associated with benign prostatic hyperplasia and overt acute urinary retention considerably affect quality of life (QOL). The administration of the International Prostatism Symptom Score (IPSS) questionnaire to a sample of 480 European men aged 50 years and older and diagnosed with lower urinary tract symptoms associated with benign prostatic hyperplasia resulted in a mean score of 4·14 on the QOL item (on a scale of 0 to 6, with 6 being the worst).5Fourcade RO Théret N Taieb C BPH USAGE Study GroupProfile and management of patients treated for the first time for lower urinary tract symptoms/benign prostatic hyperplasia in four European countries.BJU Int. 2008; 101: 1111-1118Crossref PubMed Scopus (48) Google Scholar Similar results were obtained with the American Urological Association Symptom Index (AUA-SI).6Welch G Weiniger K Barry MJ Quality-of-life impact of lower urinary tract symptom severity: results from the Health Professionals Follow-up Study.Urology. 2002; 59: 245-250Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar Additionally, nocturia (awaking in the night to urinate) is a common symptom of benign prostatic hyperplasia and its impact on daily life is evaluated with the Nocturia-specific Quality of Life (N-QoL) questionnaire. It is well established that the N-QoL score is inversely correlated with the frequency of night-time voiding.7Abraham L Hareendran A Mills IW et al.Development and validation of a quality-of-life measure for men with nocturia.Urology. 2004; 63: 481-486Summary Full Text Full Text PDF PubMed Scopus (144) Google Scholar As benign prostatic hyperplasia mainly affects older men, urologists regularly face the challenge of treating patients with several comorbidities that could equally affect health-related QOL. For example, in a large-scale prospective study of 547 patients with benign prostatic hyperplasia, a diagnosis of depression was significantly associated with higher AUA-SI scores. Also, patients with depression were three times more likely to present with moderate to severe lower urinary tract symptoms.8Johnson TV Abbasi A Ehrlich SS et al.Major depression drives severity of American Urological Association Symptom Index.Urology. 2010; 76: 1317-1320Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Moreover, the presence of cardiovascular and pulmonary complications could substantially affect postoperative outcomes.9Miernik A Roehrborn CG Benign prostatic hyperplasia treatment on its way to precision medicine: dream or reality?.Eur Urol Focus. 2022; 8: 363-364Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar For this reason, facilitating access to primary care is of utmost importance, particularly in regions in the middle and low Socio-demographic Index (SDI) quintiles. As shown by the GBD 2019 Benign Prostatic Hyperplasia Collaborators, the absolute DALY burden is highest in these regions.1GBD 2019 Benign Prostatic Hyperplasia CollaboratorsThe global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Healthy Longev. 2022; (published online Oct 20.)https://doi.org/10.1016/S2666-7568(22)00213-6Google Scholar As acknowledged in the present study, the differential burden of benign prostatic hyperplasia according to race and ethnicity remains largely unknown.1GBD 2019 Benign Prostatic Hyperplasia CollaboratorsThe global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Healthy Longev. 2022; (published online Oct 20.)https://doi.org/10.1016/S2666-7568(22)00213-6Google Scholar A retrospective study comprising two cohorts of men, from the California Men's Health Study and Research Program in Genes, Environment and Health, revealed considerable disparities in AUA-SI scores. Compared to White men, Hispanic men were more likely to have severe lower urinary tract symptoms, whereas Asian men were less likely to have moderate to severe lower urinary tract symptoms.10Van Den Eeden SK Shan J Jacobsen SJ et al.Evaluating racial/ethnic disparities in lower urinary tract symptoms in men.J Urol. 2012; 187: 185-189Crossref PubMed Scopus (29) Google Scholar Although these results might only be speculative, quantifying these disparities in terms of DALYs would be more informative. Consequently, the main challenge is to ascertain the cause of these disparities and address them on a local, regional, and global scale. We declare no competing interests. The global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019The absolute burden of benign prostatic hyperplasia is rising at an alarming rate in most of the world, particularly in low-income and middle-income countries that are currently undergoing rapid demographic and epidemiological changes. As more people are living longer worldwide, the absolute burden of benign prostatic hyperplasia is expected to continue to rise in the coming years, highlighting the importance of monitoring and planning for future health system strain. Full-Text PDF Open Access